The influence of patient complexity and nurses` experience on haemodynamic decision-making following cardiac surgery

Critical care nurses’ haemodynamic decision-making in the immediate postoperative cardiac surgical context is complex. To optimise patient outcomes, nurses of varying levels of experience are required to make complex decisions rapidly and accurately. In a dynamic clinical context such as critical care, the quality of such decision-making is likely to vary considerably. The aim of this study was to describe variability of nurses’ haemodynamic decision-making in the 2-hour period after cardiac surgery as a function of interplay between decision complexity, nurses’ levels of experience, and the support provided. A descriptive study based on naturalistic decision-making was used. Data were collected using continuous non-participant observation of clinical practice for a 2-hour period and follow-up interview. Purposive sampling was used to recruit 38 nurses for inclusion in the study. The quality of nurses’ decision-making was influenced by interplay between the complexity of patients’ haemodynamic presentations, nurses’ levels of cardiac surgical intensive care experience, and the form of decision support provided by nursing colleagues. Two factors specifically influenced decision-making quality: nurses’ utilisation of evidence for practice and the experience levels of both nurses and their colleagues. The findings have implications for staff resourcing decisions and postoperative patient management, and may be used to inform nurses’ professional development and education.

Patient or consumer? The colonization of the psychiatric clinic

Information is given a privileged place in the psychiatric clinic, as illustrated by the prevalence and volume of data to be collected and forms to be completed by psychiatric nurses. Information though is different to knowledge. The present paper argues that information is part of a managerial discourse that implies commodification whereas knowledge is part of a clinical discourse that allows room for the suffering of the patient. Information belongs to the discourse of managerialism, one that positions the patient as customer/consumer and in doing so renders them unsuffering. The patient's suffering is silenced by their construction as a consumer. The discourse of managerialism seeks a complete data set of information. By way of contrast, another discourse, that of psychoanalysis offers the institution the idea that there are always holes, gaps, and uncertainty. The idea of uncertainty, gaps, things remaining unknown and a limit sits uncomfortably with the dominant discourse of managerialism; one that demands no limits, complete data sets, and many satisfied customers. This market model of managerialism denies the potential of the therapeutic relationship; that something curative might be produced via the transference. In addition, the managerialist discourse potentially positions the patient as both illegitimate and unsuffering.

Student and supervisor perspectives in a computer-mediated research relationship

A brief narrative description of the journal article, document, or resource. This paper presents the reflective perspectives of the student and supervisor in a successful computer-mediated research relationship at Deakin University (Australia). Key contributing factors are discussed in a dialog format covering the role of computer-mediated communication (CMC), the projection of social presence, student self-efficacy beliefs, the role of information and communication technology (ICT), and interaction in online professional networks. Drawing on relevant theory, inherent challenges are addressed, informing some concluding suggestions as to how supervision might become more responsive to the emergent forms of research learning being experienced by escalating numbers of postgraduate students studying at a distance via ICT.

Research or professional development?

Generally, teachers’ contact with academics tends to take two forms: either they are the ‘subjects’ of research which is done on or for them; or they are the recipients of professional development which is again done to or for them. In both cases the teachers are positioned in relatively passive and powerless relationships.

This paper describes a research project undertaken in 2002 wherein I explored the possibilities of constructing research as a collaborative project between academics and teachers. In this project I attempted to establish a relationship with teachers as co-researchers who conducted parts of the research process themselves, including data collection and analysis.

This paper explores the differences in perceptions of this research relationship and reflects on the contradictions in the statements made by the teachers during discussions on the benefits of the research project. These contradictory statements have led me to ask questions of myself as an academic and a researcher, and of the research process I designed. These questions are the focus for this paper and include: Was I engaging in ‘research as usual’ under the guise of engaging teachers in co-researcher practices? What kinds of discourses were operating in our discussions and how did these discourses work to position the teachers? How am I implicated in the construction of these positionings?

Professional development : the singing ear sees and does

This paper argues that professional development is seen as one element that can lead to the types of change that create more effective schools and improve the learning outcomes of students (Rhodes and Houghton-Hill, 2000). As change is a multifaceted phenomenon that teachers find difficult, it questions and challenges education reform that requires teachers to significantly change their practices and approaches to teaching without significant long-term ongoing support for that change. While there is an emphasis on teachers to be lifelong learners and teaching is viewed as a dynamic and growing profession, many teachers will require ongoing professional development to support such change. This paper examines the relationship between professional growth and professional development and its impact on teacher change. This paper concludes with some views from artists-in-residence and from music teachers regarding onsite professional development and the need for ongoing professional development specifically in African music. The authors contend that an expanded program of professional development in music is likely to be more effective if it is onsite and long-term where broad educational views are considered and participants’ knowledge valued.

Working and learning in vocational education and training in the knowledge era : final report of the professional development for the future project

This Report summarises the outcomes of the phases of the Professional
Development for the Future Project and presents the implications of this research for professional development of staff in Vocational Education and Training (VET), as they become knowledge workers.

These shifts are occurring within the knowledge era. Distinguishing features of this era are summarised into four broad areas:
- the importance and value placed on knowledge in organisations
- the time span of discretion
- the complexity of relationships, and
- the ubiquitous nature of information and communication technology.

It is within this context that work is currently performed, and understanding this context provides the foundation for considering new capabilities required in the knowledge era.
Key capabilities required of knowledge workers to work effectively in the
knowledge era were drawn together from an analysis of the theoretical literature and the results of interviews with knowledge workers. The core capabilities identified include:
- adaptive problem solving – becoming designers as well as problem -
solvers
- rapid knowledge gathering and sharing with others
- discriminating between relevant and irrelevant information, and
- understanding and working effectively with the organisation’s culture.

Knowledge era characteristics and knowledge worker capabilities have been mapped to each other illustrating conceptual linkages between these two areas.

Professional development themes drawn from interviews with knowledge
workers are presented. While global trends in knowledge work have been well documented, the impact of these trends on the capabilities of workers, and the ways in which knowledge workers develop these capabilities is less well understood. Their learning methods challenge our current thinking in relation to the ways in which workers acquire skills and knowledge. Some of the professional development methods include seeking exposure to new ideas from a wide variety of sources, embracing intense learning opportunities, and using relationships to increase knowledge.

‘Thought pieces’ (see p17 ff) commissioned for this Project, as well as
subsequent interviews with the authors, provided further insights into the
professional development of knowledge workers. The implications of these insights are an extension of earlier themes and emphasise:
- the emergent nature of knowledge work
- the importance of relationships that facilitate knowledge sharing
- coherent conversations and dialogue
- collaborative work and generosity.

A key insight is the shift from thinking about knowledge work in terms of
borrowed knowledge to an emphasis on generated knowledge within a context.

Data from focus groups of the Project provide further insights for knowledge worker professional development. These augment the perspectives of the earlier data analysis but also add greater emphasis to:
- the clear and direct relationship between professional development and
work and career aspirations of knowledge workers,
- the relationship of professional development to the organisational
mission, and
- the issues of managing and leading knowledge workers and their
development.

As part of this analysis the defining features of organisational life in VET were reviewed in relation to effective professional development of knowledge workers.

The final section of the Report revisits the core dimensions of the Project.
Concise commentaries on working and learning in the knowledge era,
professional development in the knowledge era, and leadership and
management in the knowledge era are presented.

The Report concludes with a discussion of the enablers of professional
development for knowledge workers in VET. This discussion is introduced by a re-statement of the VET sector’s positioning in the knowledge era and the consequences of this for VET managers an d staff in terms of complexity, uncertainty and diminished prospects for accurate predictiveness. The enablers comprised:
- integration of information technology into socio -technical systems
- greater understanding of the organisation from within
- connecting staff to the organisation’s fundamental identity
- connecting to the work and career trajectories of workers
- establishing work structures which integrate the use of professional
development resources with knowledge work
- providing workers with the autonomy to design their own professional
development activities
- building professional development into the iterative nature of knowledge
work, and
- creating organisational contexts that value intuitive thinking and working.

Professional development needs to be thou ght of in a much broader context in the knowledge era. What each VET staff member knows and shares will become increasingly central to their work, and in that sense all VET workers require capabilities for knowledge work. This report accurately describes t he VET context, the capabilities required, and the organisational enablers that will promote ‘knowing’ and thus embed a new style of professional development within VET.

Reconstructing child welfare through participatory and child centred professional practice

This questionnaire study examined the adjustment of 245 lone-parenting women following marital separation. A composite model included intrapsychic variables as intervening between demographic and contextual variables and adjustment (life satisfaction). Regression analyses showed that the demographic and contextual variables were partially mediated by the intrapsychic variables. The path model indicated that the intrapsychic variables (sense of coherence, control, depression, and grief) had a direct impact on life satisfaction and that there was an indirect path for depression through sense of coherence (SOC) and control. It was concluded that the intrapsychic variables had a more powerful relationship with women's post-separation life satisfaction than did the demographic/contextual variables. Social implications and recommendations for future policy are considered.

Broadcasting technology and its influence on sport broadcaster inter-organisational relationship formation

Technical developments in television have resulted in major changes to the delivery of sport. One significant change is the development of relationships between clubs and sport broadcasters. This research identified the technology that is emerging in sport broadcasting, and the impact that this technology has on the potential for Inter-Organisational Relationship (IOR) formation between sport broadcasters and Australian-based professional football clubs, taken from the perspective of the sport broadcaster. Six preconditions for IOR formation were considered, including uncertainty, knowledge/expertise, resource acquisition, adaptive efficiency, regulation and strategic enhancement. In-depth interviews with senior managers of eight sport broadcasting organisations were undertaken with the resulting data analysed, and the emergent themes identified. Results indicate that sport broadcasters were not willing to enter into IORs with professional football clubs.

Diversities in the professional organization of accountants : a comparability study with insights from the Chinese experience

While spatial, historical and cultural variations across different countries have prevented any generalisation to be made of the professionalization process, various analytical themes can be said to have emerged in scholarly inquires relating to the professional organization of accountants. In highlighting these broad themes, this study argues that they have all revolved around one important relationship-that of the state and the accounting profession. The dynamics and the fluid nature of this intriguing relationship is further captured and contrasted in this study through an investigation of an episode of intra-professional conflict during the professionalization experience of the Chinese accountants.

Does an evidence-based sedation protocol improve practice and patient outcomes in critical care?

Learning Objective 1: compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care.

Learning Objective 2: explain the contrasting international research findings on sedation protocol implementation.
Minimization of sedation in critical care patients has recently received widespread support. Professional organizations internationally have published sedation management guidelines for critically ill patients to improve the use of research in practice, decrease practice variability and shorten mechanical ventilation duration. Innovations in practice have included the introduction of decision making protocols, daily sedation interruptions and new drugs and monitoring technologies. The aim of this study was to compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care setting.

A randomized, controlled trial design was used to study 312 mechanically ventilated adult patients in a general critical care unit at an Australian metropolitan teaching hospital. Patients were randomly assigned to receive protocol directed sedation management developed from evidence based guidelines (n=153) or usual clinical practice (n=159).

The median (95% CI) duration of ventilation was 58 hrs (44–78 hrs) for patients in the non-protocol group and 79 hrs (56–93) for those patients in the protocol group (p=0.20). Results were not significant for length of stay in critical care or hospital, the frequency of tracheostomies, and unplanned extubations. A Cox proportional hazards model estimated that protocol directed sedation management was associated with a 22% decrease (95% CI: 40% decrease to 2% increase, p=0.07) in the occurrence of successful weaning from mechanical ventilation.

Few randomized controlled trials have evaluated the effectiveness of protocol-directed sedation outside of North America. This study highlights the lack of transferability between different settings and different models of care. Qualified, high intensity nursing in the Australian critical care setting facilitates rapid, responsive decisions for sedation management and an increased success rate for weaning from mechanical ventilation.

Enhancing patient engagement in chronic disease self-management support initiatives in Australia : the need for an integrated approach

♦ Although emphasis on the prevention of chronic disease is important, governments in Australia need to balance this with continued assistance to the 77% of Australians reported to have at least one long-term medical condition.

♦ Self-management support is provided by health care and community services to enhance patients’ ability to care for their chronic conditions in a cooperative framework.

♦ In Australia, there is a range of self-management support initiatives that have targeted patients (most notably, chronic disease self-management education programs) and health professionals (financial incentives, education and training).

♦ To date, there has been little coordination or integration of these self-management initiatives to enhance the patient–health professional clinical encounter.

♦ If self-management support is to work, there is a need to better understand the infrastructure, systems and training that are required to engage the key stakeholders — patients, carers, health professionals, and health care organisations.

♦ A coordinated approach is required in implementing these elements within existing and new health service models to enhance uptake and sustainability.

Detection of depression in patients with low vision

Purpose. Depression is common in people with vision impairment and further reduces levels of functioning independent of vision loss. However, depression most often remains undetected and untreated this group. Eye health  professionals (EHPs) (ophthalmic nurses, ophthalmologists, optometrists, and orthoptists) and rehabilitation workers (RWs) may be able to play a role in detecting depression. This study aimed to identify current practice and investigate factors associated with depression management strategies.
Methods. A self-administered cross-sectional survey of EHPs and RWs assessed current practice including confidence in working with depressed people with vision impairment; barriers to recognition, assessment, and management of depression; beliefs about the consequences, duration, and efficacy of treatment for depression in individuals with vision impariment.
Results. Ninety-four participants aged 23 to 69 years took part. Thirty-seven participants (39.8%) stated that they attempted to identify depression as part of patient management, with RWs significantly more likely to do so (n = 17, 60.7%) than EHPs (n = 20, 30.8%; p = 0.007). Intention to identify depression was not associated with sociodemographic factors, professional experience in eye care services, or the length and number of patient consultations, but a significant relationship was found for confidence, barriers, and beliefs about depression (p < 0.05). No consistent depression management strategy emerged and a range of barriers were highlighted.
Conclusions. Training programs are needed to provide EHPs and RWs with the skills and resources to address depression in people with vision loss under their care and to support the development of procedures by which concerns about depression can be identified objectively, documented, and included as part of a referral to appropriate services.

Relationship between hypoactive sexual desire disorder and aging

Objective: Explore the association between Hypoactive Sexual Desire Disorder (HSDD) and aging. The American Foundation of Urologic Disease and the American Psychiatric Association stipulate that HSDD is only diagnosed when both low sexual desire and sexually related personal distress are present.
Design : Community-based, cross-sectional study.
Setting : Europe (UK, Germany, France, Italy) and the USA.
Patient(s) Women aged 20-70 in sexual relationships participating in the Women’s International Study of Health and Sexuality (n=1998 Europe, n=1591 USA).
Intervention(s) : No interventions were administered.
Main Outcome Measures : Self-administered questionnaire that included two validated instruments: Profile of Female Sexual Function© measured sexual desire; Personal Distress Scale© measured sexual distress. Women with low desire and distress were considered to have HSDD.
Results : The proportion of European women with low desire increased from 11% amongst women aged 20-29 years to 53% amongst women aged 60-70 years. The proportion of American women with low desire displayed a trend towards an increase with age. In the 20-29 year age group 65% of European women and 67% of American women with low sexual desire were distressed by it. This decreased to 22% and 37%, respectively, in the 60-70 year age group. In Europe and the USA the prevalence of HSDD in the population did not change significantly with age (6-13% in Europe, 12-19% in the USA).
Conclusions: The proportion of women with low desire increased with age while the proportion of women distressed about their low desire decreased with age. Consequently, the prevalence of HSDD remained essentially constant with age. This may explain why no association between HSDD and age is often reported in the literature.

Culture, language, and patient safety : making the link

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a ‘resident pathogen’ within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture–language–patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

The moral imperative of designating patient safety and quality care as a national nursing research priority

Since the early 1990s, research studies conducted respectively in the USA, UK and Australia have found that between 4 and 16.6 per cent of patients suffer from some kind of harm (including permanent disability and death) as a result of human errors and adverse events while in hospital. It has been further estimated that approximately 50 per cent of these human errors/adverse events resulting in harm could have been prevented. In response to the significant financial, social, and political implications of these figures, a range of processes have been put in place in an attempt to improve patient safety and quality care in Australia. Nonetheless, it is evident that more can be done to improve the status quo. One process that warrants consideration is that of peak health professional groups and organisations providing active leadership in the promotion of patient safety, such as by making a visible and recognisable commitment to patient safety as a strategic research priority area. In this paper it is contended that, given the moral importance of patient safety and quality care in nursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focussed public attention to patient safety and quality care as a national research priority.